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Infectious Disease – Diverticulitis
DIVERTICULITIS
ESSENTIALS DESCRIPTION
• A diverticulum is a pouch or sac that forms when the mucous membrane herniates through a weakness in the GI tract's muscle layer.
• Diverticula can develop anywhere in the gastrointestinal tract, but they are most frequently found in the colon, which is where the vasa recta, or perforating arteries, enter.
Diverticulitis is an inflammation of the diverticulum, while diverticulosis and diverticular illness simply refer to the existence of non-inflamed diverticula.
The study of epidemiology
• Although the prevalence is higher in Western nations, it is challenging to determine because only 10–25% of diverticulitis clinically appears.
• In the United States, diverticulitis causes more than 130,000 admissions each year.
• The ratio of men to women is equal.
• The prevalence rises with age, with less than 5% of patients under 40 and 65–80% over 40-70 years.
• While right-sided diverticulitis is more common in Asia, the majority of diverticulitis in the Western world affects the descending and sigmoid colon.
RISK FACTORS: Western diets that are low in dietary fiber and high in refined carbs have been linked in epidemiologic research.
Diverticulitis is more common in immunocompromised individuals, such as those who have had solid organ transplants; it has also been linked to sedentary lifestyles and obesity.
OVERALL PREVENTION
It has been suggested that maintaining a high-fiber diet will reduce transluminal pressure and enhance stool bulk.
The etiology of diverticular illness is hypothesized to be due to decreased stool bulk and is caused by elevated intraluminal pressure at weak spots where the vasa recta, which are perforating arteries, penetrate the colonic wall.
because of a reduction in dietary fiber. • It is believed that elevated intraluminal pressure causes the intestinal wall to erode, leading to inflammation, if diverticula are established. In consequence, inflammation causes additional harm linked to either macro or microperforations.
Anaerobes and gram-negative bacilli make up the majority of the polymicrobial flora that causes infection. According to Hinchey's criteria, complicated diverticulitis entails the creation of a fluid collection and falls into one of four categories:
Patients with tiny, localized pericolonic abscesses are included in stage I.
In stage II, there are bigger abscesses.
Patients in stage III have widespread suppurative peritonitis.
Frank fecal peritonitis is indicated by stage IV.
COMMON CONNECTED CIRCUMSTANCES
Inflammatory bowel disease and colon cancer
History of Diagnosis
• The majority of people with acute colonic diverticulitis are asymptomatic, however the condition might vary in severity.
• Although the presentation varies depending on comorbidities (diabetes, steroids, chemotherapy, etc.), it can be described as follows:
Low-grade fever and abdominal pain, which typically starts in the epigastric area before moving to the lower left quadrant Rebound soreness and guarding may be caused by obstruction or perforation.
• Changes in bowel patterns, such diarrhea, could occur.
• Recurrent urinary tract infections, fecaluria, or pneumaturia can occur if a colovesical fistula is present.
PHYSICAL EXAMINATION: Usually, the left lower region experiences tenderness.
quadrant and, if punctured, is frequently followed by peritoneal irritation (tenderness in the muscles, rebound, and guarding).
• In cases with widespread peritonitis, either a free rupture of an uninflamed diverticulum or the rupture of a peridiverticular abscess has taken place.
• If the location of inflammation is near the rectum, a rectal examination may show a painful mass.
• Rectal hemorrhage, which is rarely severe and is often tiny, can cause trace guaiac-positive stool in 25% of patients.
ANALYSIS & INTERPRETATION Lab Polymorphonuclear leukocytosis is frequently observed.
Imagining
• Diverticula can be seen with a contrast enema, but this does not prove or disprove the existence of diverticulitis.
• CT is the safest and most economical diagnostic technique, and it may also be used to treat abscesses. CT has a sensitivity of 93% to 97% and a specificity of almost 100%.
• The following are signs of acute diverticulitis on CT:
The presence of one diverticulum or several diverticula; inflammation of the dangerous fat
The discovery of a peridiverticular abscess; thickening of the intestinal wall to greater than 4 mm
• Ultrasonography is recommended by a number of writers for the diagnosis and management of acute diverticulitis. However, abdominal pain may make it impossible to apply the necessary amount of external pressure to properly see the intra-abdominal contents, ultrasonography is more operator-dependent than CT, and image quality is frequently subpar in obese individuals.
Diagnostic Techniques and Other
• If endoscopic assessment is done while diverticulitis is acute, there is a risk of perforation.
• After the acute process has subsided, it's critical to establish a potential underlying diagnosis, such as inflammatory bowel disease or cancer.
Pathological Results
Ulceration, crypt abscesses, and lymphoplasmacytic infiltration are characteristics that resemble Crohn's disease or ulcerative colitis.
DIFFERENTIAL DIAGNOSIS
• Because it manifests at a little younger age than left-sided diverticulitis, right-sided diverticulitis is sometimes mistaken for appendicitis. If a redundant colon is located in the right lower quadrant or suprapubic area, sigmoid diverticulitis may also appear to be acute appendicitis. Luminal narrowing and extravasation are also consistent with the diagnosis of Crohn's disease, but multiple diverticula and segmental sigmoid narrowing or extravasation of contrast material on barium enema examination or CT study with oral contrast suggest the presence of diverticulitis.
Treatment medications include: 500 mg of ciprofloxacin PO b.i.d. and 500 mg of metronidazole PO t.i.d. OR: 500 mg of trimethoprim-sulfamethoxazole double strength PO b.i.d. and 500 mg of metronidazole PO t.i.d.
• 875 mg PO b.i.d. of amoxicillin-clavulanate.
• Depending on the clinical response, the duration may vary, but one should anticipate 7–10 days.
ADDITIONAL MEDICATION
Overall Actions
• It makes sense to start empirical antibiotic treatment right away for patients whose clinical examinations confidently diagnose diverticulitis.
• Broad-spectrum antibiotic therapy that targets anaerobic and gram-negative bacteria may be started as an outpatient treatment for a patient who has a modest initial illness and can tolerate oral consumption.
microbes.
Referral Issues
The patient should be admitted for intravenous antimicrobial treatment if they have high stage diverticulitis, cannot tolerate oral intake, or are not improving with oral antimicrobial medication. Section II, "Peritonitis," covers the treatment of secondary peritonitis or perforated diverticulitis.
Other Treatments
If the patient is not improving after two to three days of treatment, a follow-up CT scan and surgical consultation are recommended.
OTHER PROCEDURES AND SURGERY
• Conservative measures have a lesser chance of resolving abscesses larger than 4 cm. Percutaneous drainage frequently increases the likelihood of resolution without requiring emergency surgery.
• To permanently remove the possibility of recurrence, a one-stage resection is advised following the resolution of the acute episode. Each situation should be examined separately.
• Approximately 10% of diverticulitis patients may need
urgent surgical intervention. The following are among the reasons for an urgent colonic resection: - Peritonitis - Free gas perforation observed on imaging (stage III and IV)
Critical conditions, such as sepsis
• When peritonitis is present, a two-stage operation is still the safest option.
According to recent findings, the first therapeutic approach for patients with peridiverticular abscesses larger than 5 cm in diameter is radiologically assisted percutaneous drainage.
Laparoscopic lavage is a recent development in the surgical treatment of diverticular disease. Since this probably indicates a more malignant diverticular condition, some writers recommend elective surgery for patients under 40 years of age following their first episode of diverticulitis.
•
Immunocompromised patient groups need extra care because their clinical manifestations can be inconspicuous. Because diverticulitis can advance quickly to sepsis and a potentially fatal infection, experts advise thinking about surgery during the initial episode.
Considering the patient
Clinical stability, tolerating oral intake, and discharge criteria
Continuing Care Follow-Up Suggestions
• The patient should be advised to continue eating a high-fiber diet after the initial episode has passed. A recurrence rate of at least 50% has been reported in earlier research.
• To rule out an underlying colonic malignancy, a colonoscopy is recommended.
• Approximately 20–30% of individuals with acute diverticulitis will eventually need surgery. On the other hand, 70% of senior citizens who experience one simple bout of diverticulitis won't experience another clinical recurrence.
DIET: As tolerated, the patient should be moved from a clear diet to a low residue diet.
• Dietary fiber supplementation has been demonstrated to lower intraluminal pressures, decrease gastrointestinal transit time, and increase stool weight, all of which lower the risk of diverticulosis.
PROGNOSIS
The mortality risk is roughly 5% for Hinchey's Stage I and II, 13% for Stage III, and 43% for Stage IV.
DIFFICULTIES
Free perforation, which causes severe peritonitis, sepsis, and shock, especially in the elderly, is one of the complications of diverticulitis. Adherent omentum or nearby tissues like the bladder or small bowel may shut off the perforation. A fistula may develop if adjacent organs are affected or if an abscess bursts into an organ in the vicinity.
• Although comparatively rare, colonic blockage can occur during recurrent bouts of acute diverticulitis. There is a slightly higher incidence of small-bowel obstruction, particularly when there is a large peridiverticular abscess. Severe pericolitis can result in a fibrous stricture around the bowel, which can mimic a neoplasm and be linked to colonic obstruction. Pylephlebitis is a rare but dangerous side effect of diverticular disease that should be suspected in patients with diverticulitis who develop hepatic abscesses or jaundice.
DIVERTICULITIS
ESSENTIALS DESCRIPTION
• A diverticulum is a pouch or sac that forms when the mucous membrane herniates through a weakness in the GI tract's muscle layer.
• Diverticula can develop anywhere in the gastrointestinal tract, but they are most frequently found in the colon, which is where the vasa recta, or perforating arteries, enter.
Diverticulitis is an inflammation of the diverticulum, while diverticulosis and diverticular illness simply refer to the existence of non-inflamed diverticula.
The study of epidemiology
• Although the prevalence is higher in Western nations, it is challenging to determine because only 10–25% of diverticulitis clinically appears.
• In the United States, diverticulitis causes more than 130,000 admissions each year.
• The ratio of men to women is equal.
• The prevalence rises with age, with less than 5% of patients under 40 and 65–80% over 40-70 years.
• While right-sided diverticulitis is more common in Asia, the majority of diverticulitis in the Western world affects the descending and sigmoid colon.
RISK FACTORS: Western diets that are low in dietary fiber and high in refined carbs have been linked in epidemiologic research.
Diverticulitis is more common in immunocompromised individuals, such as those who have had solid organ transplants; it has also been linked to sedentary lifestyles and obesity.
OVERALL PREVENTION
It has been suggested that maintaining a high-fiber diet will reduce transluminal pressure and enhance stool bulk.
The etiology of diverticular illness is hypothesized to be due to decreased stool bulk and is caused by elevated intraluminal pressure at weak spots where the vasa recta, which are perforating arteries, penetrate the colonic wall.
because of a reduction in dietary fiber. • It is believed that elevated intraluminal pressure causes the intestinal wall to erode, leading to inflammation, if diverticula are established. In consequence, inflammation causes additional harm linked to either macro or microperforations.
Anaerobes and gram-negative bacilli make up the majority of the polymicrobial flora that causes infection. According to Hinchey's criteria, complicated diverticulitis entails the creation of a fluid collection and falls into one of four categories:
Patients with tiny, localized pericolonic abscesses are included in stage I.
In stage II, there are bigger abscesses.
Patients in stage III have widespread suppurative peritonitis.
Frank fecal peritonitis is indicated by stage IV.
COMMON CONNECTED CIRCUMSTANCES
Inflammatory bowel disease and colon cancer
History of Diagnosis
• The majority of people with acute colonic diverticulitis are asymptomatic, however the condition might vary in severity.
• Although the presentation varies depending on comorbidities (diabetes, steroids, chemotherapy, etc.), it can be described as follows:
Low-grade fever and abdominal pain, which typically starts in the epigastric area before moving to the lower left quadrant Rebound soreness and guarding may be caused by obstruction or perforation.
• Changes in bowel patterns, such diarrhea, could occur.
• Recurrent urinary tract infections, fecaluria, or pneumaturia can occur if a colovesical fistula is present.
PHYSICAL EXAMINATION: Usually, the left lower region experiences tenderness.
quadrant and, if punctured, is frequently followed by peritoneal irritation (tenderness in the muscles, rebound, and guarding).
• In cases with widespread peritonitis, either a free rupture of an uninflamed diverticulum or the rupture of a peridiverticular abscess has taken place.
• If the location of inflammation is near the rectum, a rectal examination may show a painful mass.
• Rectal hemorrhage, which is rarely severe and is often tiny, can cause trace guaiac-positive stool in 25% of patients.
ANALYSIS & INTERPRETATION Lab Polymorphonuclear leukocytosis is frequently observed.
Imagining
• Diverticula can be seen with a contrast enema, but this does not prove or disprove the existence of diverticulitis.
• CT is the safest and most economical diagnostic technique, and it may also be used to treat abscesses. CT has a sensitivity of 93% to 97% and a specificity of almost 100%.
• The following are signs of acute diverticulitis on CT:
The presence of one diverticulum or several diverticula; inflammation of the dangerous fat
The discovery of a peridiverticular abscess; thickening of the intestinal wall to greater than 4 mm
• Ultrasonography is recommended by a number of writers for the diagnosis and management of acute diverticulitis. However, abdominal pain may make it impossible to apply the necessary amount of external pressure to properly see the intra-abdominal contents, ultrasonography is more operator-dependent than CT, and image quality is frequently subpar in obese individuals.
Diagnostic Techniques and Other
• If endoscopic assessment is done while diverticulitis is acute, there is a risk of perforation.
• After the acute process has subsided, it's critical to establish a potential underlying diagnosis, such as inflammatory bowel disease or cancer.
Pathological Results
Ulceration, crypt abscesses, and lymphoplasmacytic infiltration are characteristics that resemble Crohn's disease or ulcerative colitis.
DIFFERENTIAL DIAGNOSIS
• Because it manifests at a little younger age than left-sided diverticulitis, right-sided diverticulitis is sometimes mistaken for appendicitis. If a redundant colon is located in the right lower quadrant or suprapubic area, sigmoid diverticulitis may also appear to be acute appendicitis. Luminal narrowing and extravasation are also consistent with the diagnosis of Crohn's disease, but multiple diverticula and segmental sigmoid narrowing or extravasation of contrast material on barium enema examination or CT study with oral contrast suggest the presence of diverticulitis.
Treatment medications include: 500 mg of ciprofloxacin PO b.i.d. and 500 mg of metronidazole PO t.i.d. OR: 500 mg of trimethoprim-sulfamethoxazole double strength PO b.i.d. and 500 mg of metronidazole PO t.i.d.
• 875 mg PO b.i.d. of amoxicillin-clavulanate.
• Depending on the clinical response, the duration may vary, but one should anticipate 7–10 days.
ADDITIONAL MEDICATION
Overall Actions
• It makes sense to start empirical antibiotic treatment right away for patients whose clinical examinations confidently diagnose diverticulitis.
• Broad-spectrum antibiotic therapy that targets anaerobic and gram-negative bacteria may be started as an outpatient treatment for a patient who has a modest initial illness and can tolerate oral consumption.
microbes.
Referral Issues
The patient should be admitted for intravenous antimicrobial treatment if they have high stage diverticulitis, cannot tolerate oral intake, or are not improving with oral antimicrobial medication. Section II, "Peritonitis," covers the treatment of secondary peritonitis or perforated diverticulitis.
Other Treatments
If the patient is not improving after two to three days of treatment, a follow-up CT scan and surgical consultation are recommended.
OTHER PROCEDURES AND SURGERY
• Conservative measures have a lesser chance of resolving abscesses larger than 4 cm. Percutaneous drainage frequently increases the likelihood of resolution without requiring emergency surgery.
• To permanently remove the possibility of recurrence, a one-stage resection is advised following the resolution of the acute episode. Each situation should be examined separately.
• Approximately 10% of diverticulitis patients may need
urgent surgical intervention. The following are among the reasons for an urgent colonic resection: - Peritonitis - Free gas perforation observed on imaging (stage III and IV)
Critical conditions, such as sepsis
• When peritonitis is present, a two-stage operation is still the safest option.
According to recent findings, the first therapeutic approach for patients with peridiverticular abscesses larger than 5 cm in diameter is radiologically assisted percutaneous drainage.
Laparoscopic lavage is a recent development in the surgical treatment of diverticular disease. Since this probably indicates a more malignant diverticular condition, some writers recommend elective surgery for patients under 40 years of age following their first episode of diverticulitis.
•
Immunocompromised patient groups need extra care because their clinical manifestations can be inconspicuous. Because diverticulitis can advance quickly to sepsis and a potentially fatal infection, experts advise thinking about surgery during the initial episode.
Considering the patient
Clinical stability, tolerating oral intake, and discharge criteria
Continuing Care Follow-Up Suggestions
• The patient should be advised to continue eating a high-fiber diet after the initial episode has passed. A recurrence rate of at least 50% has been reported in earlier research.
• To rule out an underlying colonic malignancy, a colonoscopy is recommended.
• Approximately 20–30% of individuals with acute diverticulitis will eventually need surgery. On the other hand, 70% of senior citizens who experience one simple bout of diverticulitis won't experience another clinical recurrence.
DIET: As tolerated, the patient should be moved from a clear diet to a low residue diet.
• Dietary fiber supplementation has been demonstrated to lower intraluminal pressures, decrease gastrointestinal transit time, and increase stool weight, all of which lower the risk of diverticulosis.
PROGNOSIS
The mortality risk is roughly 5% for Hinchey's Stage I and II, 13% for Stage III, and 43% for Stage IV.
DIFFICULTIES
Free perforation, which causes severe peritonitis, sepsis, and shock, especially in the elderly, is one of the complications of diverticulitis. Adherent omentum or nearby tissues like the bladder or small bowel may shut off the perforation. A fistula may develop if adjacent organs are affected or if an abscess bursts into an organ in the vicinity.
• Although comparatively rare, colonic blockage can occur during recurrent bouts of acute diverticulitis. There is a slightly higher incidence of small-bowel obstruction, particularly when there is a large peridiverticular abscess. Severe pericolitis can result in a fibrous stricture around the bowel, which can mimic a neoplasm and be linked to colonic obstruction. Pylephlebitis is a rare but dangerous side effect of diverticular disease that should be suspected in patients with diverticulitis who develop hepatic abscesses or jaundice.
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